Management of hypoglycemia - Essay Example

Management of Hypoglycemia in an Inpatient using the Gibbs Model: Evaluating, Analysing, and Reflecting on a Specific Diabetic Care Issue in Relationto a Specific Clinical Practice Development in Reference to the National Standards Framework for Diabetes Introduction: Diabetes is increasingly common throughout the world. Its prevalence is well over 5% in many developed countries and is rising in the United Kingdom. While talking about its prevalence, it is to be remembered that diabetes is caused by our genes and our personal environment, which is created by our lifestyles. For people with diabetes, whether type 1 or type 2, the disorder can have a profound influence on all aspects of life and can affect most organs of the body. There is no cure for diabetes, and once occurs, it is present for life. The increasing appreciation throughout the healthcare industry for clinical decisions to be driven by sound scientific evidence represents an opportunity for the patients, practitioners, and healthcare planners alike in that it shapes the delivery of care on the basis of evidence of effectiveness. The past two decades have seen considerable progress in producing evidence to support treatments aimed at reducing the risk of diabetes and its complications. This indicates a shift of focus from treatment of effects to treatment of cause, where prophylactic interventions are more important than just therapeutic measures. This means caregiving now does not await the disease to happen; rather, the care tends to identify population or individual who would develop diabetes in a later life (Foster, 1998, p 2069-2070). Definitions: Diabetes mellitus occurs either because of lack of insulin or because of the presence of factors that oppose the action of insulin. Therefore, it can be defined as a chronic disease caused by inherited and/or acquired deficiency in production of insulin by the pancreas or by the ineffectiveness of the insulin that is produced. The result of insufficient action of insulin is an increase in blood glucose concentration or hyperglycaemia. This increased glucose would damage many of the body systems, most significantly blood vessels and nerves. Data from genetic, epidemiological, and aetiologic studies have led to the improvement of the understanding of the aetiology and pathogenesis of diabetes. From my experience in the clinical placement, I have come across patients during clinical practice with varied presentations. Whatever may be the mode of diagnosis, persistently elevated plasma glucose in the fasting state would lead to the diagnosis of diabetes mellitus even if the patient is asymptomatic. In the ward while working with the patients of diabetes, frequent monitoring of plasma glucose and adjusting the diet or medication is a normal routine nursing activity. I have see a venous plasma glucose concentration of 140 mg/dL in at least two separate occasions or plasma glucose concentration of 200 mg/dL 2 hours following ingestion of 75 g of glucose would constitute a diagnosis of diabetes mellitus(Foster, 1998, p 2080). Insulin: Diabetes is treated with insulin in the inpatients with or without oral hypoglycaemic agents. Since the disease at least partly results from insulin deficit, insulin is required for many patients with diabetes mellitus type 2. If no oral agents are used for treatment, all diet-responsive type 2 diabetics must be treated with insulin. My observation suggests that it is fairly easy to control the symptoms of diabetes with insulin, and as a nurse working in the ward, I know it is difficult to maintain a normal blood sugar throughout the day even with the use of multiple injections. It is also to be mentioned that the patient treated with insulin by injection cannot reproduce the physiologic changes in a normal patient in response to a diet load. Thus, if enough insulin is given to keep the postprandial glucose normal, too much insulin will be present during the postabsorptive phase, and hypoglycaemia will result. As a result, insulin therapy is guided mainly by adjustments and trial and error, and no single standard exists for patterns of administration of insulin. Hypoglycemia is a medical emergency that needs urgent management by a person whose knowledge about diabetes and hypoglycaemia is thorough to be able to take care of all physiologic and pathologic aspects of a hypoglycaemic episode in a diabetic. Most frequently maladjustment of the dose of insulin, poor monitoring of plasma glucose levels, and inadequate concepts regarding the pathogenesis on the part of a nurse cause this clinical phenomenon (Foster and Rubenstien, 1998, p 2081-2083). It is well known in the practice circuit that insulin has no 'right' dose, no regimen is absolute in the sense that depending on clinical situation, the dose needs to be adjusted. It should be in the right time, in the right way, and in the right amount. These three rights are reserved by another right, the right of the patient to choose the offered therapy, and that is the most important ethical requirement. The practitioner must be open minded enough with flexibility to change the regimen if it is found to be unsuitable. For example, as I reflect, I have seen patients who fail to have an adequate glycaemic control despite increasing dosage of insulin since they have unfortunately developed insulin resistance. The practitioner should immediately change the type, schedule, and dose of the regimen. This calls for hands on knowledge of different preparations available for diabetic therapy. Another difficult situation is patients with gradually increasing dosage of oral hypoglycaemic therapy that is failing to control the blood sugar (Guide to Diabetes, 2007). This arises as a result of poor pancreatic reserve, and these patients must be initiated with insulin therapy as soon as possible to accomplish an adequate care. In this critical essay, I am going to critically reflect one of my experiences of management of hypoglycemic episodes in a patient, and I will use Gibbs model to do this. Reflection: For ethical reasons, the name and identity of the patient would remain undisclosed, and for our purposes, we would refer to her as Carmen, which obviously is not her original name. Carmen has been admitted this time to the hospital with a very low blood glucose level of 1.3 mmol. I was assigned her care in the hospital, and after a literal battle, she has now stabilized. I came to know, after three years of independent travel around the world, she has settled into her own flat and is currently almost through with a "hair and beauty course" at a local college. She has a physically demanding part time job in a local 'gentleman's club'. She is very fashion conscious and tries very hard to maintain her tall elegant body shape, and hence, she has refused to acknowledge her newly diagnosed brittle diabetes and has consistently neglected the management with insulin and diet. She is consistently non-compliant with therapy, and as a result, she is suffering from complications of diabetes, such as, loss of vision and numerous other diabetic crises. Despite this, Carmen has thus far refused to modify her behaviour and is, therefore, at risk of such events. This time, she has been admitted with a hypoglycaemic attack, the sugar levels were way too far below the normal levels. On the face of a hypoglycaemic attack, this work will discuss how care and treatment of Carmen are planned and delivered. In doing so, this work will analyze the rationale of any particular intervention, justifying that with existing knowledge of evidenced-based practice. This work will also analyze and elaborate the preventative measures and the role of diabetic education in preventing complications of diabetes in a patient like Carmen, so she can learn to live with diabetes (NICE 2002b). The story tells about a woman who is in college in hair and a beauty course and is extremely conscious about fashion and weight. This lady is hardworking too, apart from college, she has a physically demanding job in a local gentleman's club. The instructions to strike a balance between blood sugar levels and timely food, the schedule of insulin injections, and increased demand of body energy for a physically demanding job would create trouble. For a woman who is anxious about her body weight, would always skip a meal or two to maintain her appearance, plus the college and work at the club will have a toll on the time management. Apart from that, she might not be educated well about the nature of her disease; she might not understand the seriousness of the diet and insulin programme. She might be working out putting a load on the body in terms of glucose control. She has fragile diabetes or brittle diabetes, which is type 1 diabetes that causes constant disruption of lifestyle from recurrent attacks of hypoglycaemia or hyperglycaemia from many causes, such as, therapeutic errors, emotional disorders, intercurrent illnesses, or self- or career-induced episodes. The problem of hypoglycaemia is more common in insulin-dependent diabetics. Carmen is suffering from type 1 diabetes (DoH 2002). Diabetic Emergencies: There are three types of acute metabolic diabetic emergencies. The first and most common is hypoglycaemia, occurring most frequently in type 1 diabetes. These attacks are dangerous and portends to serious and even fatal outcome. The two other are diabetic ketoacidosis and hyperosmolar nonketotic coma. Diabetic ketoacidosis often results as a complication of NIDDM or type 2 diabetes. The result is very high glucose and ketone levels in the blood. Hyperosmolar nonketotic coma is also an acute complication of type 2 or non-insulin dependent diabetes mellitus. The reason I am talking about these complications is that, all such patients will present in a similar manner with unconsciousness and fainting attacks. To be able to manage appropriately, it is important to accurately diagnose which condition the patient is suffering from. An immediate plasma glucose test would discern this condition from others (Unger and Foster, 1997, p343-365). The practitioner has an important quasi passive role to play here; she will explain the options and present all the pros and cons, and the final decision will be made by the patients themselves. To be able to present the options efficiently, the practitioner in the general area would know how insulin works, why insulin is needed, the physiology of normal insulin, the types of insulin available for therapy, the delivery devices, benefits and disadvantages of different delivery devices, and common regimens. In patients with whom oral hypoglycaemic agents are not that effective, the common mistake a practitioner does is instituting insulin therapy and stopping the OHAs. Combining oral agents and insulin regimen has many advantages, and one of them is reduced requirement of both. The other advantages as I have noticed from my placement are better glycaemic control while insulin is being introduced and dosage adjusted, the patient has an option of remaining on a simpler treatment regimen easier to execute, with less risk of hypoglycaemia and less risk of weight gain(Tomky, 2005, p 39-43). Hypoglycaemia: In diabetics, the nighttime 3 A.M. goal sugar level is to be greater than 3.6 mmol/L. In type 1 diabetics, a deficiency of glucose below that level would produce a symptom complex of muscular weakness and incoordination, mental confusion, and sweating. This usually results from a combination of relative insulin overdose and insufficient intake of carbohydrates. Carmen's presentation blood sugar was 1.3 mmol/L, which was way below the required range at that hour, 4 A.M. As a part of the therapeutic programme, there must have been efforts to keep both fasting plasma glucose and postprandial diet-induced hyperglycemia. In Carmen's case, both missing a meal for figure-consciousness, doing unexpected exercise in the form of workout or workload in college and in her part time job, might have been causative. The possible chain of events might have been, night before, she might have had a huge workload, she took the insulin for night before dinner, and she failed to eat the prescribed dinner, and in her case, the protective counter-regulatory mechanisms failed to activate, since she has taken exogenous insulin, and food was not available to the body (Farmer, 2004, 93). Normal Values in Diabetes: The ideal fasting blood sugar level should be 3.9 to 5.6 mmol/L, preprandial should be the same that is 3.9 to 5.6 mmol/L, one hour post prandial should be ideally less than 8.9 mmol/L, acceptable up to less than 11.1 mmol/L, and at 3 A.M. in the morning it should be greater than 3.6 mmol/L. Values in these ranges indicate a good diabetic control (Seley and Weinger, 2007, 616-626). Carmen's Presentation: A rapid steep fall in blood glucose would induce excessive secretion of epinephrine and norpeinephrine. Since brain mostly relies on glucose for its source of energy, deprivation of brain glucose would lead to neuroglycopaenia and central nervous system dysfunction. Carmen would have presented with sweating, tremor, tachycardia, anxiety, and hunger due to rapid epinephrine release. She would have dizziness, headache, clouding of vision superimposed on her basic visual compromise as a result of diabetes, blunted mental acuity, loss of fine motor skill, abnormal behaviour, and confusion. She had chances of convulsions and loss of consciousness if the hypoglycaemia would have prolonged without intervention in our care. Her glucose at presentation was 1.3 mmol/L. That is the reason, she was semiconscious, not unconscious (Masayuki et al, 2002, 800-802). Usually cerebral symptoms predominate when the glucose level approaches 1 mmol/L. Since the time of presentation is 3 A.M. and she has type 1 diabetes, it can be assumed that she has fasting hypoglycaemia. In her case, the problem was excess glucose utilization with a relative excess of insulin, where her liver failed to sustain an adequate glucose level of at least 2.8 mmol/L. Carmen is a diabetic, and she had been admitted with symptoms and tests supporting hypoglycaemia, it is safe to conclude that no special diagnostic tests are necessary because these episodes are almost always related to therapy (Metchich, Petit, and Inzucchi, 2002, 317-323). Hypoglycaemia, hence, is a medical emergency, and this requires nursing team to be vigilant in detecting signs and symptoms, and the goals should be reversing the hypoglycaemia, treating any complications without compromising glycaemic control in baseline diabetes. Although most patients reverse from hypoglycaemia completely, if not reversed, it can progress from just lethargy to coma and then to death. The adrenergic symptoms serve as warning symptoms for precipitation of neurobehavioural symptoms. Inpatient team members must be alert to adrenergic hypoglycaemia signs and symptoms including anxiety, irritability, dizziness, diaphoresis, pallor, tachycardia, headache, shakiness, and hunger. If these warning signs are ignored or not monitored, the blood glucose level will continue to fall, and more severe hypoglycaemia would lead to alteration of mental function that proceeds to headache, malaise, impaired concentration, confusion, disorientation, irritability, lethargy, slurred speech, irrational or uncontrolled behaviour, and ultimately a state of stupor or semi-consciousness (Briscoe and Davis, 2006, 115-121). A nurse in charge should be vigilant about the progressive signs of CNS dysfunction including focal seizures, hemiplegia, proximal choreoathetosis, or evolving deep coma, papillary dilatation, shallow breathing, bradycardia, and hypotonicity that may result from further reduction of blood glucose levels. Since most patients with diabetes never suffer from such symptoms, the chances for them happening in Carmen's case is less, yet it is better to be vigilant about these signs and symptoms. On presentation, Carmen was profoundly hypoglycaemic and she was semi-conscious, and her individual awareness as well as responses for comfort and self-preservation did no longer operate. In this situation, the patient is totally dependent on nurse's skills for her comfort needs and life. The normal reflexes protecting the conscious person are lost, and their protective function is assumed by the nurse until the patient's status is restored to normal ( Directorate of Nursing Affairs, p1-1). On initial encounter, my initial responsibility would be to ascertain, establish, and maintain a clear airway. In Carmen's case, she was breathing fine, hence there was no immediate necessity to establish the airway, but a vigil for any compromise was instituted and at the bedside, a correct size airway, suction device, and oxygen were arranged. Her level of consciousness was assessed repeatedly every hour during the first 48 hours, and the vital signs were recorded every 15 minutes until she stabilized. Systolic blood pressure is the best vital sign to distinguish whether the impaired consciousness is due to cerebral dysfunction. Hypotension is the usual finding, and this would indicate a metabolic brain dysfunction. So frequent recording of these signs would indicate any impairment upon evaluation, and appropriate measures could have been instituted as early as possible. Maintenance of fluid and electrolyte balance comes next, and it was very important in Carmen's case. Intravenous equipment should be ready at the bedside (Atallah and Amm-Azar, 2006, 205-214). Regarding hypoglycaemia, a possible protocol should be worked out depending on her response to therapy. On presentation and admission, there had been a rapid assessment of symptoms. Carmen was responsive but stuporous. The MD was notified immediately, and an intravenous (IV) access was established. Since IV access was promptly available, there was not much of haemodynamic instability, and 50 mL of 50% dextrose was immediately given. The nursing would be prepared to administer glucagon 1 mg IV since the problem in Carmen's case is impaired glucagon response to fasting. Monitoring of neurological signs to assess improvement or deterioration and fluid balance should be recorded in neurological and intake output observations charts. Carmen was a little restless, hence bed rails were arranged, and her semi-consciousness precludes appropriate hygiene, hence eye care, oral care equipments were instituted, and with the hope that she will recover soon, feeding equipments were arranged. After the appropriate nursing cares were all begun, it was time to assess her response to the intravenous dextrose. A blood glucose monitoring system was utilized to assess blood sugars every 15 minutes, and Carmen was catheterized and connected to a leg bag for accurate assessment of the output. The MD visit took place, and MD orders were followed. Due to her semi-consciousness, it was decided that until she regains full consciousness, no attempt would be made for oral delivery of glucose, rather a protocol of monitoring, assessment, and blood sugars will guide repeated doses of 15 to 20 g of dextrose via IV route, and since this has a chance of elevating the blood sugars to the diabetic range, strict monitoring of blood sugar levels would be the best idea. After 24 hours, Carmen was conscious but weak and fatigued, he blood sugars were still in the hypoglycaemic range, her vital signs were approaching normalcy. The MD visit happened, it was advised that there will be a trial of oral intake while monitoring of vital signs, neurological signs, fluid and electrolyte balance, and blood sugar levels will continue every four hours. This would continue until the glucose levels approach near normal with oral glucose drinks of 15 to 20 g. Towards the end of the second day, Carmen could sit up, bed rails and catheter were taken out, and a protocol for 6 hourly monitoring was put in place. She was having glucose drinks, and her blood sugars were in the range of 5s, and once it was 7.8, she was allowed snacks and meal, and she started to interact with the staff. This exchange and experience was an opportunity to educate Carmen about her disease. The first thing the team can do is review the signs and symptoms of hypoglycaemia with Carmen. The approach was to recognize the fact that it is very difficult to accept that one has a chronic disease that requires a change in lifestyle. It is particularly true in diabetics who are young, and they are almost forced to accept the injection insulin treatment, which is not still the ideal mode of therapy, and they are forced to follow a rigorous dietary regimen. The primary reaction hence can range from denial with an accompanying refusal to cooperate. The nursing staff should be aware of the fact that the emotional response to diabetes often hampers treatment, and they should make every effort to bring the patient to a middle ground of acknowledging the disease and its complications and responding prudently without becoming obsessed. In fact, Carmen's problems can be handled if common sense is coupled with sympathy and firmness. It is best to take the opportunity of an acute episode of illness to use teaching materials, chart, persuasion, suggestions about a new life style where the patient will participate in carrying out a preventative care plan to make her understand her disease, or in essence, Carmen should be educated about diabetes. It may also be appropriate to offer cautious hope that the disease will be handled better in the future than is possible now. The perfect goal will be to teach Carmen to live with diabetes (RCN, 2006). The initial regimen of choice would be a long-acting insulin, such as, Lantus or Lemivir. long-acting peakless insulin in the morning or whenever convenient depending on the daily routine. The NICE recommendation is to provide the dose at the same time each day NICE (2002b). Those who are taking OHA would take the prescribed adjusted dose along with that. Long-acting basal insulin is best suitable for those who need assistance in administration because that depends on the time of the provider. This is usually adequate to control both day and nighttime high blood glucose. This regimen would help an incidental case of absolutely restricted lifestyle where stringent insulin dosage may result in hypoglycaemia. Finally, this regimen is perfectly suitable for individuals who are reluctant to have insulin mainly because the mode of administration is injection. This being a single daily injection can preclude that excuse. However, this needs a great degree of flexibility on the part of the practitioner since this needs to be weighed against having the openness to deal with possible surges in blood glucose levels in response to meals and need to be adjusted accordingly. This was also an opportunity to educate Carmen about her disease, how treatment is important in terms of adherence to the regimen and in terms of lifestyle factors. I educated Carmen once she was stabilized and out of danger, and she seemed to have understood her problem and had promised to follow the treatment regimen as much as possible. The skill of an educator is another important skill that a practitioner must possess or develop. She is recommended to have explicit encounters with patient mainly initiating first a discussion programme to address the needs of the patient. The patients must understand what is meant by a poor glycaemic control and the implications thereof. The education should cover areas, such as, disease progression and risks; insulin resistance; poor glycaemic control symptoms; the need for exogenous insulin; how and why to test blood glucose; insulin devices including injection techniques and sites; identification, avoidance, and prevention of hypoglycaemic events; the sick rules; diet and daily exercises; driving; and finally, to train to adjust the dosage (DoH 2002). Reflection: Applying Gibbs principles, it is very evident that this reflection would consolidate my understandings about this frequent complication of diabetes. The nursing plan would demonstrate knowledge and the more the knowledge, the management plan would be more effective. While reflecting, I found that I could have been a little more confident in initiating the managements after contacting the MD. I had waited for a long time for him to come, and in hypoglycaemic episodes, this delay may predispose to complications and delayed recovery. The pulse oxymeter would have been available in the ward because that would be able to measure the status of arterial oxygenation in the patient, and this value would help discern the diagnosis quickly. Otherwise, I had implemented the standards of management and guidelines of management of a hypoglycaemic patient accurately, and this is an opportunity to rectify, update, and consolidate knowledge that could come of help in future practice. References Atallah, C. and Amm-Azar, M., 2006. Management of diabetes mellitus. J Med Liban, Oct 2006; 54(4): 205-14. Briscoe, V.J. and Davis, S.J., (2006). Hypoglycemia in Type 1 and Type 2 Diabetes: Physiology, Pathophysiology, and Management. Clinical Diabetes; 24: 115 - 121. Directorate of Nursing Affairs, General Nursing Procedures, Unconscious patient, page 1-1. Donna Tomky, MSN, RN, C-ANP, Detection, Prevention, and Treatment of Hypoglycemia in the Hospital, From Research to Practice /Diabetes Care in the Hospital, p.39-43, Diabetes Spectrum Volume 18, Number 1, 2005 Farmer, A., (2004). The evidence base for diabetes care. Evid. Based Med.; 9: 93. Foster, D. E., Diabetes Mellitus, Harrison's Principles of Internal Medicine, ch. 334, p 2069-2070, McGraw-Hill, 1998 Foster, D. E., Diabetes Mellitus, Harrison's Principles of Internal Medicine, ch. 334, p 2080, McGraw-Hill, 1998 Foster, D. W. and Rubenstien, A.H., Hypoglycemia, Harrison's Principles of Internal Medicine, ch. 335, p 2081-2083, McGraw-Hill, 1998 Guide to Diabetes http://www.diabetes.org.uk/ Diabetes UK, Guide to Diabetes, accessed on February 28, 2008. Masayuki et al., 2002, Using Vital Signs To Diagnose Impaired Consciousness: Cross Sectional Observational Study, BMJ;325;800- Metchich LN, Petit WA, and Inzucchi SE: The Most Common Type Of Hypoglycemia Is Insulin-Induced Hypoglycemia In Diabetes. Am J Med 113:317-323, 2002. National Standards Framework For Diabetes (DoH 2002), DOH, London. NICE (2002b). Management of type 2 diabetes - blood glucose (guideline G).NICE: London. RCN, (2006). Starting insulin treatment in adults with Type 2 diabetes. RCN guidance for nurses May 2004, revised March 2006. Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN. Seley, J.J. and Weinger, K., (2007). The State of the Science on Nursing Best Practices for Diabetes Self-Management. The Diabetes Educator; 33: 616 - 626. Unger, R.H. and Foster D.W., Diabetes Mellitus, In Williams Text Book of Endocrinology, 9th Ed., JD Wilson, DW Foster (eds). Philadelphia, Saunders, 1997. Read More